Five cases are described where minute foci of adenocarcinoma have been demonstrated in the mesorectum several centimetres distal to the apparent lower edge of a rectal cancer. In 2 of these there was no other evidence of lymphatic spread of the tumour. In orthodox anterior resection much of this tissue remains in the pelvis, and its is suggested that these foci might lead to suture-line or pelvic recurrence. Total excision of the mesorectum has, therefore, been carried out as a part of over 100 consecutive anterior resections. Fifty of these, which were classified as 'curative' or 'conceivably curative' operations, have now been followed for over 2 years with no pelvic or staple-line recurrence.

OBJECTIVE

To examine the role of total mesorectal excision in the management of rectal cancer.

METHODS

A prospective consecutive case series.

METHODS

A district hospital and referral center in Basingstoke, England.

METHODS

Five hundred nineteen surgical patients with adenocarcinoma of the rectum treated for cure or palliation.

METHODS

Anterior resections (n = 465) with low stapled anastomoses (407 total mesorectal excisions), abdominoperineal resections (n = 37), Hartmann resections (n = 10), local excisions (n = 4), and laparotomy only (n = 3). Preoperative radiotherapy was used in 49 patients (7 with abdominoperineal resections, 38 with anterior resections, 3 with Hartmann resections, and 1 with laparotomy).

METHODS

Local recurrence and cancer-specific survival.

RESULTS

Cancer-specific survival of all surgically treated patients was 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% (95% confidence interval, 2%-10%) at 5 years and 8% (95% confidence interval, 2%-14%) at 10 years. In 405 "curative" resections, the local recurrence rate was 3% (95% confidence interval, 0%-5%) at 5 years and 4% (95% confidence interval, 0%-8%) at 10 years. Disease-free survival in this group was 80% at 5 years and 78% at 10 years. An analysis of histopathological risk factors for recurrence indicates only the Dukes stage, extramural vascular invasion, and tumor differentiation as variables in these results.

CONCLUSIONS

Rectal cancer can be cured by surgical therapy alone in 2 of 3 patients undergoing surgical excision in all stages and in 4 of 5 patients having curative resections. In future clinical trials of adjuvant chemotherapy and radiotherapy, strategies should incorporate total mesorectal excision as the surgical procedure of choice.

BACKGROUND

Local control and survival following surgical treatment of rectal cancer have been improved by the introduction of total mesorectal excision (TME). The aim of this study was to determine the nationwide impact of the introduction and training of TME on recurrence and survival in rectal cancer.

METHODS

Short- and long-term outcomes of a recently published trial of rectal cancer surgery (TME trial) were compared with results from an older trial (cancer recurrence and blood transfusion (CRAB) trial), in which conventional surgery was performed without quality control. Only patients who were operated on with curative intent and who did not receive neoadjuvant radiotherapy were studied. Differences in clinicopathological characteristics were corrected for by multivariate analysis. To ensure valid comparisons, only events that occurred within 2 years of operation were analysed with regard to long-term outcome.

RESULTS

In the univariate analysis, a higher clinical anastomotic leak rate was found in patients following low anterior resection in the TME trial (P = 0.046), but this association was not significant in the multivariate analysis. The local recurrence rate decreased from 16 per cent in the CRAB trial to 9 per cent in the TME trial, and type of operation (conventional (CRAB trial) versus TME (TME trial)) was an independent predictor of local recurrence (P = 0.002). Type of operation was also an independent predictor of overall survival (P = 0.019); there was a higher survival rate in the TME trial.

CONCLUSIONS

The introduction and training of TME has led to improved long-term outcome of patients with rectal cancer in the Netherlands.

BACKGROUND

To obtain information on the contemporary management of colorectal cancer in the UK to assist in the development of management guidelines, an independent, 1-year population audit was carried out in Trent Region and Wales.

METHODS

Data were collected on all patients admitted to hospital with a new diagnosis of colorectal cancer in a 1-year period.

RESULTS

Of 3520 patients, 3221 (91.5 per cent) had surgery. Emergency/urgent operations were carried out as the first procedure in 552 (17.1 per cent). Resection of the primary disease was achieved in 2859 (81.2 per cent) and this was deemed curative in 2070 (58.8 per cent). Twenty-one per cent of all patients had metastatic disease at presentation. Overall, 30-day operative mortality was 7.6 per cent (21.7 per cent for emergency/urgent and 5.5 per cent for scheduled/elective procedures). Anastomotic dehiscence occurred in 105 patients (4.9 per cent); this was 3.9 per cent after colonic resections and 7.9 per cent after anterior rectal resections. Elective rectal excision resulted in a permanent stoma in 486 of 1054 patients (46 per cent).

CONCLUSIONS

This initial report from a comprehensive, independent audit of colorectal cancer management shows improvement in some aspects of treatment as evidenced by improved anastomotic dehiscence and stoma rates when compared with previous studies. However, there has been little improvement in the proportion of patients presenting with advanced disease, and curative resection rates remain low.

BACKGROUND

The technique of total mesorectal excision (TME) increases the risk of anastomotic leakage. The impact of postoperative morbidity of TME on longterm survival has never been described. We retrospectively analyzed factors that might influence survival after TME for rectal cancer, including postoperative morbidity.

METHODS

From 1994 to 2001, 300 patients (192 men and 108 women; mean age, 64 years) had TME for rectal cancer. Preoperative radiotherapy was given in 202 patients. Age, gender, tumor height, size and circular invasion of the tumor, pathologic tumor and nodal status, distal and circumferential margins, number of lymph nodes analyzed, type of surgery, postoperative pelvic sepsis, preoperative radiotherapy, and adjuvant chemotherapy were examined; their association with overall and disease-free survival was evaluated by the log-rank test in univariate analysis and by multivariable Cox proportional hazards analysis.

RESULTS

Postoperative morbidity was 38% (113 of 300 patients) and included 18% (54 of 300 patients) pelvic sepsis. The local recurrence rate was 6% (18 of 300 patients), and the distant metastasis rate was 24% (73 of 300 patients). Recurrence was three times more frequent distally than locally, including patients with pelvic sepsis The 5-year overall and disease-free survival rates were 72% and 60%, respectively. Independent predictors of overall survival were age older than 64 years (odds ration [OR]=2.19, 95% CI 1.32 to 4.17), pelvic sepsis (OR=2.06, 95% CI 1.10 to 3.87), circumferential surgical margin (OR=3.19, 95% CI 1.67 to 6.09), pathologic tumor (OR=2.69, 95% CI1.23 to 5.88), and nodal status (OR=3.18, 95% CI 1.79 to 5.64). Independent predictors of disease-free survival were pelvic sepsis (OR=2.17, 95% CI 1.31 to 3.58), circumferential surgical margin (OR=2.61, 95 CI 1.52 to 4.49), pathologic tumor (OR=1.82, 95% CI 1.04 to 3.20), and nodal status (OR=2.67, 95% CI 1.68 to 4.23). Patients with pelvic sepsis had a 5-year disease-free survival of 39% compared with 65% without pelvic sepsis (p<0.001).

CONCLUSIONS

After TME for rectal cancer, pelvic sepsis is a common complication that is associated with increased risk of distant recurrence and decreased longterm survival. Efforts are necessary to decrease postoperative morbidity in surgical treatment of rectal cancer.

BACKGROUND

Local recurrence (LR) of cancer after rectal surgery is followed by significant morbidity and mortality. Since the introduction of total mesorectal excision (TME) the rates of LR have decreased in many centres. The aim of this retrospective study was to investigate the effect of TME on the recurrence rates of rectal cancer and the impact of the surgeons.

METHODS

All patients resected for invasive rectal cancer from 1990 until 2000 were initially included in the study. From February 1994, TME was adopted as the standard treatment (TME group). Before this period, rectal surgery was performed by the non-TME technique (non-TME group). To obtain homogeneity, patients who underwent preoperative irradiation, emergency operations, pre- or intraoperative bowel perforation, residual tumour stage (R1,2) including Dukes' D stage and postoperative mortality within 31 days, were excluded. 139 patients in the non-TME group and 181 patients in the TME group were found eligible for analyses.

RESULTS

The estimated LR rate at 1, 3 and 5 years was 7, 15 and 17% (non-TME) versus 4, 9 and 9% (TME) (p = 0.046, log-rank test). The anastomotic leakage rate was 6% (non-TME) versus 4% (TME) (not significant). Perioperative blood loss >500 ml, reoperations during the hospital stay and lymph node (N) stage were the independent risk factors for LR in the multivariate analysis. The case volume did not significantly influence LR rates. However, the variability of individual surgical results was reduced after the introduction of TME.

CONCLUSIONS

TME yields significantly lower LR rates compared with traditional surgery. Since the introduction of TME, experience with rectal surgery has been gathered by a limited number of surgeons. The results of individual surgeons have consistently improved and the variability of individual surgical results is now at a lower level.

The role of total mesorectal excision for rectal cancer treatment is one of the most exciting findings in surgical oncology of the recent years. The patient's prognosis largely depends on the surgical quality of rectal resection. The excision of the cancer bearing rectum has to follow very precisely along the mesorectal fascia by sharp dissection without damaging the mesorectum itself. This technique reduces the local recurrence rate to below 10% and allows long-term survival in two thirds of all patients. Rectal cancers of the middle and lower third of the rectum need to be treated by total mesorectal excision down to the muscular pelvic floor, the ones of the upper third and the sigmoideo-rectal junction are appropriately treated by partial mesorectal excision down to 5 cm below the tumor. No additional survival benefit may be expected when pelvic lymphadenectomy has been performed. The direct tumor spread along the bowel wall and the lymphatic tumor spread in a caudal direction are uncommon and late findings in rectal cancer disease. Low and ultralow rectal carcinomas may therefore be treated by a sphincter preserving procedure respecting a safety margin of at least 1 to 2 cm. Thus, continence preserving surgery may be performed in over 80% of patients suffering from rectal cancer without compromising long-term outcome.